Ileana L. Piña, MD, MPH; Hugh G. Calkins, MD


November 04, 2013

In This Article

Is This Practice-Changing?

Dr. Piña: Do you think this registry finding may get into the guidelines? Do you think it may change practice?

Dr. Calkins: It is a very provocative question and the results of the study are very provocative. They start you wondering whether AF ablation reduces stroke risk and whether you can stop anticoagulation in the patient if you do an AF ablation.

Dr. Piña: That is a huge question for our doctors out there.

Dr. Calkins: I think the answer is that after AF ablation, everyone should be anticoagulated for at least 2-3 months. Then, at the 2- or 3-month point, all of the guidelines and consensus documents say that the decision of whether to continue anticoagulation should be based on stroke risk or the CHA2DS2-VASc score.

Dr. Piña: Is gender part of that score?

Dr. Calkins: Yes. There has been a shift from the CHADS2 to the CHA2DS2-VASc. The C is congestive heart failure, H is hypertension, A is age (it used to be over 75, but with the CHA2DS2-VASc it is > 65 years), D is diabetes, S is prior stroke, female gender, and vascular disease. If, after 3 months, someone is doing well but the CHA2DS2-VASc risk score is 3 or 4, it would be a mistake, in my opinion, to stop anticoagulation. That reflects the fact that we know that late reoccurrences can occur after AF ablation.

Dr. Piña: We learned in AFFIRM[3] that when you converted patients and you stopped anticoagulation, the risk of stroke went up.

Dr. Calkins: Exactly. We also know that if AF comes back after an AF ablation, it is more likely to be asymptomatic. And we know that over time, the patient's age and stroke risk score goes up. If you look at the study, it had these big headlines: "Does AF ablation reduce stroke risk? Isn't this wonderful?" I think it is easy to misinterpret the study to conclude that if my patient is doing well, I am going to stop anticoagulation, or if my patient doesn't want to take an anticoagulant, I am going to tell them to get an AF ablation to reduce stroke risk even if they are asymptomatic. That is a big mistake. This registry study clearly states that the results should not impact current recommendations and that they have to be verified. They also did not include an assessment of what anticoagulants these patients were on.

Dr. Piña: We don't know from the registry? They didn't capture that?

Dr. Calkins: Exactly. Everyone who had an AF ablation may still be on anticoagulation for all we know.

Dr. Piña: But we don't know.

Dr. Calkins: They just didn't have that data.


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